WEEK4ASSGNROBINSONN.doc - NURS 6512 Advanced Health Assessment and Diagnostic Reasoning Assignment Week 4 Patient Initials MR Age 35 Gender Male

WEEK4ASSGNROBINSONN.doc - NURS 6512 Advanced Health...

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NURS 6512: Advanced Health Assessment and Diagnostic Reasoning Assignment Week 4 Patient Initials: MR Age: 35 Gender: Male SUBJECTIVE DATA: Chief Complaint (CC): Scaly, dry, and pink patches on skin (Photo #5) History of Present Illness (HPI): MR is a 35-year-old Caucasian male presenting to the clinic today with the complaints of scaly, dry, and pink patches on his skin. The patient reports that the skin plaques have developed in his knees and elbows in the past 3 months now. MR describes the skin lesions as dry and pink patches with on and off episodes of the lesions being scaly with moderate itching. The patient complains that the itching gets worse during stress and exercising. She reports the use of over the counter moisturizing and anti- itching lotions with minimal relief. Lately, the itching has been getting worse and associated with irritating burning sensation over the past couple days which brought her to the clinic today. Medications: Amlodipine 5mg BID PO Lithium 600mg BID PO Aveeno Eczema Therapy Lotion PRN Benadryl Extra Strength Itch Relief Topical Cream PRN Allergies: Penicillin Past Medical History (PMH): Hypertension, Bipolar Disorder Past Surgical History (PSH): Bilateral Tonsillectomy (1998) Sexual/Reproductive History: If applicable, Hetero sexually active male with one partner. Sexual partner uses oral contraceptives. Personal/Social History: Denies tobacco or illicit drug use. Occasional drinker (2-3 beers every other day). Exercises 5 days a week and consumes healthy diet. Immunization History: Childhood immunization up to date. Patient refuses Influenza and Pneumococcal immunization.
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